Provider Demographics
NPI:1366758203
Name:WALL, LISA M (LICSW, CADC-II)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:LICSW, CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DUNPHY DR
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01062-9602
Mailing Address - Country:US
Mailing Address - Phone:413-320-1751
Mailing Address - Fax:
Practice Address - Street 1:120 DUNPHY DRIVE
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01062-9602
Practice Address - Country:US
Practice Address - Phone:413-230-2530
Practice Address - Fax:413-327-9523
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1225261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical